Why LDL is Not Enough: The Tests Your Doctor is Missing to Assess Your Risk of Heart Disease | Know Your Numbers

Episode 856 1h 59m


Heart disease is the world's leading cause of death. For years, the diet-heart hypothesis, which centers on high cholesterol as the primary culprit, has dominated the medical discourse. But now, we're beginning to appreciate the complexity and nuance of how the outer workings of our environment influence the inner workings of our physiology and risk for heart disease.

In today’s episode of a new series I’m calling Know Your Numbers, I deep dive into the Functional Medicine approach to assessing cardiovascular risk and why this is key to preventing and, in some cases, reversing cardiovascular disease. You can test your cardiovascular risk with Function Health, a company I co-founded. It has been a lifelong dream for me. Function is the first-ever membership that includes 100+ lab tests and personalized insights from globally renowned doctors based on your results. Join Function at FunctionHealth.com.

Recommended Diagnostics

Comprehensive lipid testing

  • Total cholesterol
  • Triglycerides
  • HDL
  • LDL
  • Apolipoprotein B (ApoB)
  • Lipoprotein fractionation (NMR)
  • Lipoprotein A
Metabolic labs
  • Insulin
  • Glucose
  • HbA1c
Additional labs
  • hs-CRP
  • Kidney
  • Liver
  • Hormones
  • Uric acid
  • oxLDL, f2 isoprostane
  • LpPLA2
  • MPO
AI-enhanced CT angiograms, imaging tests (preventative)
  • Carotid ultrasound
  • CT Coronary Angiogram
  • CT Coronary Artery Calcium Score
  • Cleerly Scan
Advanced tests
  • Lipid genetics: GB Insights
    • Familial Hypercholesterolemia
    • Lean Mass Hyperresponder / Hypercholesterolemia
  • Biomarkers of excess cholesterol production in the liver or absorption of cholesterol from the gut
Normal vs. Optimal Reference Ranges Total Cholesterol
  • “Normal”: < 200 mg/dL
  • Optimal: < 180 mg/dL
  • Conventional:
    • 0-149 mg/dL (“Normal”)
  • Functional Medicine :
    • <70 mg/dL (Optimal)
    • > 100 mg/dL (insulin resistance)
    • > 150 mg/dL (concerning)
    • > 300 mg/dL (severe, requires aggressive treatment with diet, lifestyle, and sometimes medication)
  • Conventional Medicine (“Normal”): ≧ 40 mg/dL (men); ≧ 50 mg/dL (women)
  • Functional Medicine (Optimal): > 60 mg/dL
  • Conventional Medicine (“Normal”): < 100 mg/dL
  • Functional Medicine (Optimal): < 70 mg/dL
    • Need to look at the number and size of LDL cholesterol particles (lipoprotein fractionation) to determine if cholesterol is atherogenic or benign
    • Conventional Medicine (“Normal”): 20 - 90 mg/dL; risk increases the most > 120 mg/dL
    • Functional Medicine (Optimal): 40 - 70 mg/dL
      • Those with pre-existing heart disease < 50 mg/dL
      • < 30 mg/dL indicator of other health issues (same as low cholesterol)
  • If your LDL is high and your ApoB is low, your risk of heart disease is low
  • If your LDL is normal or low and your ApoB is high, your risk of heart disease is high
  • Should be < 1,000
LDL Small
  • 0-100 nmol/L
LDL Medium
  • Optimal: < 215 nmol/L
  • Moderate: 215-301 nmol/L
  • High: > 301 nmol/L
HDL LARGE PARTICLES Optimal Reference Range
  • > 6729 nmol/L
  • Pattern A is optimal:
    • Pattern A is bigger, more buoyant, usually not associated with heart disease
  • Pattern B is a risk marker:
    • Pattern B is smaller and denser particles, which are atherosclerotic risk markers
  • Studies have shown varying risks for CAD and other CVDs at different Lp(a) cutoff points
  • Generally, the lower, the better (< 20)
    • Risk varies with age
    • Risk is higher in individuals with lower Lp(a) levels and smaller apo(a) isoforms
  • Conventional Medicine (“Normal”): <130 mg/dL
  • Functional Medicine (Optimal): 100 mg/dL or lower
  • Ideally, it should be 1:1


This episode is brought to you by AG1, Sweetgreen, and Open. The Doctor’s Farmacy podcast works with a select group of sponsors to allow for ongoing production and allow it to be zero-cost to anyone who wishes to listen to and watch the podcast.

Topics Covered

  • Prevalence of cardiovascular disease and heart attacks


  • Why conventional medicine misses the mark in assessing and treating cardiovascular disease risk and “high” cholesterol


  • The testing you should be getting to assess cardiovascular risk


  • The major root causes of heart disease


  • Cholesterol: What is it and how is it related to heart disease?


  • Insulin resistance and heart disease


  • Total cholesterol, triglycerides, HDL, LDL cholesterol, and other relevant biomarkers


  • Root causes of suboptimal biomarkers


  • Additional diagnostic testing


  • Diet, lifestyle, and supplements for reducing cardiovascular risk


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Host & Guests


Automatically generated. Please forgive any typos or errors in the following transcript. It was generated by a third party and has not been subsequently reviewed by our team.

Dr. Mark Hyman:
Coming up on this week's episode of the Doctor's Farmacy, primarily today, the major root cause aside from some of these inherited genetic lipid disorders for heart disease, and that's insulin resistance, prediabetes and diabetes. And this requires a more nuanced, personalized diet and lifestyle treatment.
Welcome to Doctor's Farmacy. I'm Dr. Mark Hyman, and this is a place for conversations that matter. And today we're diving into our special episode in my podcast series called Know Your Numbers designed to help you understand how your body works, what your own lab and biological data mean through lens of systems biology and functional medicine, which is the science of creating health. And today we're taking a deep dive into the numbers that matter to assess and..

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Ep. 856 - Why LDL is Not Enough: The Tests Your Doctor is Missing to Assess Your Risk of Heart Disease | Know...